Large hiatus hernia requiring hiatoplasty - An ongoing challenge: A case series

Evidence for the management of large hiatus herniae (HH) in children is lacking. Adult literature is conflicting with regard to risk vs. benefit profile of prosthetic mesh use; rates of dysphagia or recurrence are up to 25 % and 38 %, respectively. We aimed to assess the efficacy of using a biological tissue matrix to augment hiatoplasty.

Retrospective review of consecutive children with preoperatively identified large primary hiatal hernias by three sub-specialist surgeons between 2019 and 2024. All children underwent repair with a biological tissue matrix. Data are presented as median (IQR).

Fifteen children were included, median age 2.2 years (1.5-10.4) and weight 13.5 kg (9.8-13.3). Follow-up was 1.0 years (0.3-3.3). U-shaped hiatoplasty used OVITex® 1S and was performed laparoscopically (n = 12, 75 %) or open (n = 4, 25 %) and included a Nissen fundoplication. All had symptoms of gastro-oesophageal reflux disease (GORD). Comorbidities included cerebral palsy (n = 3, 20 %), oesophageal atresia (n = 2, 13 %), malrotation (n = 1, 7 %), oesophageal duplication cyst (n = 1, 7 %) and neurofibromatosis type 1 (n = 1, 7 %). Four (27 %) were congenital para-oesophageal hernias. The rate of resolution of GORD was 71 %. Two (13 %) had recurrence seen at endoscopy or contrast study. One of these previously had a failed open repair, and then further failed open redo HH repair and fundoplication. One patient (7 %) has dysphagia, despite having a widely patent gastro-oesophageal junction at endoscopy. There were no complications from mesh erosion.

Large HH remains a challenging condition. Our approach of augmenting hiatoplasty with an ovine reinforced tissue matrix shows favourable rates of GORD resolution, recurrence and dysphagia compared to similar pediatric series.